Suicide is one of the leading causes of male mortality. In nearly
every country in the world, more males than females end their life by
suicide. Previous research indicates male-specific risk factors include
social factors such as being unmarried, low income, and unemployment. An
analytic model of male suicide is developed, proposing that the
traditional male gender role creates a culturally-conditioned narrowing
of perceived options and cognitive rigidity when under stress that
increases male suicide risk. Suicide prevention and intervention require
recognition of the role of high traditional masculinity, situating
individual explanations within a broader social context. Based on this
theory and the few existing empirical studies, testable hypotheses are
proposed.

Keywords: suicide, men, masculinity, gender

**********

This is what my father did, he got up, showered, shaved and dressed
for work. He went downstairs and made a pot of coffee, and while it was
brewing he went outside and walked the long driveway to pick up the
newspaper. He left the paper folded on the kitchen table, poured a cup
of coffee, carried it upstairs, and put it on my mother's table.
She was still in bed, sleeping. Then he went into his study, closed the
door, and shot himself.--Joan Wickersham (2008, p. 5)

Understanding male suicide requires a social lens. This paper first
reviews the epidemiology of male suicide and research on risk factors
for male suicide. Then an analytic model is developed that interprets
male suicide as a function of male gender role extremes, and in light of
Baumeister's (1990) escape theory of suicide. As Wickersham's
(2008) haunting account of her father's suicide exemplifies (quoted
above), many male suicides do not fit a stereotype of being visibly
depressed and having made previous attempts. Focus is needed on
developing and testing explanatory theories of male suicide, and using
this evidence to tailor prevention and intervention programming toward
men. The evidence synthesized comes from many cultures, but the
diversity in gender roles around the world is great, so this paper
serves as a starting point for understanding gender, gender role and
patterns of suicide.

Death by suicide is a strikingly a male phenomenon. More men
complete suicide every year in every country in the world with one
exception, China (Joiner, 2005). In the United States, men are more than
four times as likely as women to complete suicide, a large effect (CDC,
2009). In Europe, the widest gap between men and women for suicide
mortality is found in Greece and Ireland. In England and Wales, men are
approximately three times as likely to complete suicide as women (Payne,
Swami, & Stanistreet, 2008). The consistency in epidemiological data
showing a male excess in suicide is impressive, but Canetto (2008)
cautions that epidemiological data is missing for some developing
countries, and there are cultural differences in how deaths are
recorded.

Across both genders, suicide is a significant global public health
problem. According to World Health Organization estimates, 10-20 million
people complete suicide every year. There are wide variations between
countries in terms of suicide mortality, with very low rates in some
Latin American and Muslim countries, compared with high rates in Eastern
Europe. Variations in the way suicide is recorded affect those
comparisons, particularly in countries where suicide goes against
religious beliefs, but such variations do not fully explain differences
between countries (Mann et al., 2005; Payne, 2006; WHO, 2002).

MALE SUICIDE RISK FACTORS AND PRECIPITATING CIRCUMSTANCES

The gap between women and men in suicide risk varies across the age
span in many regions of the world. In Australia, for example, the widest
gap between men and women in suicide deaths is found in young adults and
among those aged 70 and older. Similarly, in the United States the
greatest gender difference is among those aged 15-24 and those over 65.
In New Zealand, men are more than three times as likely to complete
suicide, but in younger age groups this increases to a four-fold risk
(Payne, 2006).

There are additional gender differences in suicide methods (Payne.
2006). More men use lethal methods, including firearms, hanging and
jumping. In the United States, firearms are used in nearly 60 percent of
male deaths, ranging from 23 percent in Massachusetts to 66 percent in
South Carolina. Methods used in suicide also vary with age. Three out of
every four suicides among U.S. older adults (65+) involve firearms,
compared with just over half of those aged 15-24 (Kaplan, McFarland,
& Huguet, 2009).

Some risk factor studies analyzed male and female participants
separately, as well as in aggregate, highlighting the divergent risks
for male and female suicide. A large Danish death register study
reported that males who are single, unemployed or whose income is lower
than average had a heightened risk of suicide, while those same factors
were not significant for women (Qin, Agerbo, & Mortensen, 2003). In
a large, nationally representative study in the US, education and
marital status other than married were risk factors for suicide death
for men but not for women (Denney, Rogers, Krueger, & Wadsworth,
2009). The time of marital separation has been found to be a
particularly vulnerable time for suicide death, with higher risk for
males (Wyder, Ward & De Leo, 2009). Male attempters are more likely
to be first-time attempters (Murase, Ochiai, Ueyama, Honjo, & Ohta,
2003), more likely to be underweight than average-weight (Kaplan,
McFarland, Huguet, & Newsom, 2006; Carpenter, Hasin, Allison, &
Faith, 2000), and more likely to be cigarette smokers and to have
stressors related to low income (Zhang, McKeown, Hussey, Thompson, &
Woods, 2004). Kaplan and coauthors (2006) found risk factors for suicide
included male gender, physical illness and disability, psychiatric
condition, and military veteran status.

There are both distal and proximal risk factors that are salient to
male suicide (Hufford, 2001). Risk factors of a chronic and longstanding
nature, such as alcohol dependence or psychiatric disorders, are
relatively distal factors, in contrast to proximal factors that have a
sudden onset and precipitate a crisis, such as an unexpected loss of
job, relationship, or home (Allen, Cross, and Swanner, 2005). While
substance dependence is a distal factor, acute alcohol intoxication
constitutes a proximal factor that can increase the risk of both a
suicide attempt and the use of lethal means (Hufford, 2001). In 17 US
states, over one-quarter of male suicide decedents had a blood alcohol
concentration indicative of intoxication at the time of death.
Additionally, alcohol intoxication was predictive of the use of firearms
after adjusting for other variables (Kaplan, McFarland and Hugeut,
2009).

Increased suicide risk is found in several male dominated
occupations including police officers, the military, farmers, and
physicians. These fields all have access to lethal means and a high
likelihood of work related exposure to death. Police, military
personnel, and farmers tend to use firearms to complete suicide, and
physicians are more likely to use a medication overdose (Agerbo,
Gunnell, Bond, Mortensen, & Nordentoft, 2007).

The Social Environment and Male Suicide

There has been a longstanding tension between social and individual
explanations for suicide, evident as early as Durkheim's
(1897/1997) pioneering sociological study of suicide. Durkheim made note
of the male excess in suicide, and the majority of examples he explores
were of exclusively male or male dominated segments of society such as
the military. Dublin (1962), who contributed to the development of
demographic methods starting in the early 20th century, also turned his
attention to suicide. Canetto (2008) points out when Dublin did attend
to gender differences, it was largely informed by stereotypes about men
and women. In recent decades, sociology has devoted substantial
attention to the issue of suicide (Stack, 2000), but research on the
social context and suicide has come from a range of disciplines.

As noted previously, men have higher risk of suicide following job
loss than women. According to several reviews, being unemployed is
associated with a twofold to threefold increased relative risk of death
by suicide, compared with being employed. Both aggregate-level and
case-control studies generally show that unemployment is positively
correlated with male suicide rates in several Western countries. Based
on data drawn from Danish longitudinal registers, Qin et al. (2003)
demonstrated that economic stressors such as unemployment and low income
increase suicide risk more in male than female subjects. The significant
risk factors for men, after controlling for psychiatric admission, were
unemployment, retirement, being single and sick absence. For women there
were no significant risk factors other than mental illness.

The pattern of male reactivity to unemployment has been found in an
impressive series of international studies. Among census-based cohorts
of unemployed British and Finnish men, the suicide rates were,
respectively, 1.6 and 1.9 times greater than those of the reference
populations (Jin, Shah, & Svoboda, 1995). Time-series analyses also
revealed strong aggregate-level correlations between unemployment and
suicide among young adult males in Australia (Morrell, Taylor, &
Quine, 1993). Ying and Chang (2009) showed that unemployment had a
significantly positive impact on male suicide rate but mixed impacts on
female suicide rate based on an analysis of panel data from G-7
industrial countries (Canada, France, Germany, Italy, Japan, UK, and
US). In a Swedish study involving the impact of job loss on mortality
risk, Eliason and Storrie (2009) found that the suicide mortality risk
among men increased, while there was no impact on women. Men who lost
their jobs were 2.15 times more likely to die by suicide four years
after being displaced due to plant closures in Sweden in 1987 and 1988.

There is some evidence that the influence of unemployment varies
with age. Berk, Dodd and Henry (2006) reported that the relationship
between unemployment and suicide in Australia was strongest for males in
the 20-34 year-old age range during the period of 1968-2002. Similarly,
when the unemployment rate tripled during the Hong Kong economic crisis
of the 1990s, there was a 93% increase in the rate of suicide death for
males in the 30-59 year-old category (Chen, et al, 2006). It is logical
that the impact of unemployment would be strongest in work and career
sensitive developmental stages.

The influence of economic conditions operates at least partially
independently of culture. In the US, the aggregate African-American
suicide rate has been consistently markedly lower than the rate for
whites. However, the gender discrepancy between African-American men and
women is greater than in other groups in the US: African-American men
are six times more likely to die by suicide than African-American women,
and the rate for men has increased in recent decades (Joe & Kaplan,
2001). Burr, Hartman and Matteson (1999) found that African-American
suicide rates were highest in geographical areas that had the greatest
income disparities between whites and African-Americans. The overall
lower rate of African-American suicide may stem from protective cultural
factors such as strong extended family ties, but the excess in male
suicide again likely reflects the influence of poverty, unemployment and
racism. An additional factor may be gender role orientation within the
African-American community.

The impact of historical and current poverty and social dislocation
is evident also in the elevated suicide rate for Native Americans,
approximately one and a half times the general population US rate. There
is a male excess of suicides among Native Americans, as well, peaking
with a suicide rate of two and a half times the population rate for
Native American men 15-24 years of age (Olson & Wahab, 2006). These
patterns appear to be similar among Aboriginal peoples in Australia
(Tait & Carpenter, 2010) and Canada (Laliberte & Tousignant,
2009).

In summary, unemployment may act as a proximal stressful life event
leading to suicide (Shah & Bhandarkar, 2008). Economic insecurity
may be an important antecedent variable in the causal chain leading a
person to attempt suicide (Jin, Shah, & Svoboda, 1995). The stress
associated with unemployment can differ depending on one's options
and constraints. In a later section, we argue that the traditional male
gender role narrows perceived options under stressful circumstances.
Given the connection of male suicidality to social influences, the
dominance of individualized therapeutic models of suicidal behavior
obscures critical precipitating social circumstances (Moiler, 1996).

Suicide and Homophobia

There is evidence that gay and bisexual adolescent males are at
greater risk for suicide attempts and completions (Cochran & Mays,
2008). Although some investigators

attribute suicide risk to mental health problems, others have found
that the association between suicidality and same-gender orientation in
adolescence and adult men is independent of the effects of substance use
and mental health diagnoses (Remafedi, 2008). Cochran and
Rabinowitz's (2003) analysis of Danish data showed a six-fold
increase in age-adjusted risk for completed suicide among men, but not
women, who were in registered same-sex domestic partnerships when
compared to married persons. Herrell et al. (1999) found that gay men
were 6.5 times as likely as their fraternal co-twins to have attempted
suicide and the relatively high risk was not explained by mental health
or substance abuse disorders. In two large studies of students conducted
in Minnesota and Massachusetts, the relative risks of attempted suicide
for bisexual and gay male students were, respectively, 7.1 and 3.4 times
higher than heterosexual male peers (Remafedi, 2008).

Safren and Heimberg (1999) found similar elevated rates of suicidal
behavior for gay and lesbian youth, but when the increased psychosocial
stress for these youth was controlled for, the group difference became
much smaller. This indicates that much of the difference in suicidal
ideation and behavior for sexual minority youth is due to the stress of
alienation from friends and family members related to continued
homophobia. In addition to the stress of homophobia of others, gay and
bisexual men may struggle with internalized homophobia.

MALES AND VIOLENT MEANS OF SUICIDE

As noted earlier, men are more prone to use violent, highly lethal
means such as guns, hanging or jumping. Eighty-percent of all suicide
deaths in the U.S. involve males, and the majority of those deaths
involve the use of firearms (Miller, Lippmann, Azrael, & Hemenway,
2007). Among elderly men, guns are the most common method of suicide,
accounting for nearly 80% of such deaths (Kaplan et al., 2009).

The use of violent means by male attempters has been interpreted as
consistent with the traditional male gender role (Canetto, 1997; Stack
& Wasserman, 2009). Men are more likely to shoot themselves in the
head rather than in the body, and are more likely to use rifles or shot
guns to complete suicide (Stack & Wasserman, 2009). This is
convergent with Canetto's (1997) summary of research on youth views
of suicide and suicide attempts, where youth tended to view attempts as
feminine, and suicide completion as masculine.

The male pattern of suicidality also includes impulsive attempts
with lethal means, often while under the influence of drugs or alcohol,
and in the absence of long term substance abuse or mental health
problems. Kaplan and colleagues (2006) statistically classified
decedents into those who displayed a long-term risk profile, and those
who fit a short term profile. Those in the short term risk group were
more likely to have been male, white, and to use firearms to complete
suicide. This impulsive type of suicide is the most difficult to
prevent, as warning signs are only evident in a brief window before an
attempt, and attempts tend to be fatal.

MEN AND SUICIDE: DEPRESSION AND BEYOND

The review of risk factors indicates that men are more likely to
develop suicidal behavior following major life transitions, from
unemployment, and being single than women with the same stressors. The
fields of suicide research and prevention have been understandably
focused on the link between suicide and depression. Suicidal thoughts
and behavior are by definition linked to depression by inclusion in
diagnostic criteria (American Psychiatric Association, 2000), and
approximately 20% of people with major depressive disorder report
suicidal behavior or thoughts (Borges, et al., 2006). The majority of
suicide research is conducted with clinical samples, reinforcing the
link of depression and suicide.

The importance of moving beyond a depression-centered view of male
suicide came into focus in one of the authors' analysis of the
National Violent Death Reporting System (NVDRS) data (Kaplan, McFarland,
& Huguet, 2009). This analysis used suicide death data from 16
states and included information on decedent mental health from proxy
data. From the tables in the article, it can be calculated that 62% of
male decedents had no mental health history or diagnosis, in contrast to
42% of female decedents. Only half as many men (16%) as women (32%) had
a previous suicide attempt. The typical male suicide decedent had no
history of mental health treatment and no previous suicide attempts.
Given that men are less likely to seek mental health treatment, a
proportion of these men probably had depression or other mental
disorders. Our hypothesis is traditional masculinity would account for
additional variance in suicidality beyond depression.

From this data it is clear that the majority of male suicide
decedents would not have been included in a study of attempters, nor in
a study based on a clinical sample. In other words, the majority of male
suicide decedents are drawn from a different population than the
populations on which much of our knowledge about suicide is based upon,
clinical samples and previous attempters. This explains in part how the
dynamics of male suicide continue to be overlooked and poorly
understood.

Reframing Individual Psychopathology as a Social Problem

The gender discrepancy of rates of depression among male and female
suicide decedents has been noted before, and explained as male decedents
are suffering from other psychopathology: such as personality disorders,
substance dependence, or an unrecognized male depressive syndrome. We
review these arguments as a step toward offering an alternate,
socio-cultural lens on male suicide.

The personality disorder argument to explain the non-depressed male
suicide is based in studies that retrospectively diagnose decedents. A
meta-analytic review of 29 studies of suicide decedents found that male
decedents were more likely to fit personality disorder criteria, and
female decedents mood disorder criteria (Arsenault-Lapierre, Kim &
Turecki, 2004). Ernst and colleagues (2004) examined cases of suicide
decedents who did not meet DSM Axis I criteria, and concluded that there
was evidence of underlying psychopathology in nearly all the cases.

The male-depressive syndrome argument is partially convergent with
the personality disorder explanation, as the criteria proposed for male
depression overlap with personality disorder criteria. For example,
Walinder and Rutz (2001) suggest a new diagnostic category of male
depression that includes low stress tolerance, acting out behavior, low
impulse control and substance abuse. Note that the DSM criteria for
borderline and antisocial personalities include anger, impulsivity, and
substance abuse. Van Praag (1996) proposed male depression as an
"anxiety/aggression-driven" type, and identified the overlap
with diagnostic criteria and neurotransmitter similarities of the
proposed male depression diagnosis and personality disorders.

Recognizing undiagnosed personality problems and correctly
identifying depressed men are essential for clinical practice. However,
there are neglected social and public health explanations for male
depression and suicide. The traits identified by personality disorder
diagnosis, and the male depression syndrome, are also consistent with
extremes of the male gender role. The emphasis on action, impulsivity,
and the acceptability of anger are a part of the social norm of
masculinity that sets the context for male suicide. Are these
characteristics better accounted for by personality disorders, male
depression, or high traditional masculinity? On one level, this is an
empirical question that could be tested in a study that includes
measures of all these constructs. On another level, it is a
philosophical question of specifying a model and choosing variables and
level of analysis.

Men and the Escape Theory of Suicide

Baumeister's (1990) escape theory of suicide, and
Hufford's (2001) subsequent elaboration of it in analyzing alcohol
use and suicide, provides a helpful framework for male suicide. The
theory is at the individual level, but the dynamics described by escape
theory reflect consequences of the dominant male gender role. Though
Baumeister (1990) did not emphasize gender in his theory, he argued that
depression was not a satisfying explanation for the majority of suicidal
behavior, and his theory sought to explain both depressed and
non-depressed suicidal acts. Stated simply, escape theory proposes that
suicidal acts are more likely when an individual is emotionally
distressed by a self-perception of failure and this leads to a narrowing
cognitive state of limited emotion, attention, and lowered inhibition.
The suicidal act is an effort to escape an intolerable view of self and
the related negative affect.

This state of cognitive rigidity is particularly salient to
understanding male suicide. The male gender role, with its emphasis on a
high expectation of strength, providing materially for others, and the
acceptability of anger and violence, provides a social script that
combines with cognitive rigidity with often fatal consequences. Hufford
(2001) termed the empirical evidence for cognitive constriction while
intoxicated, "alcohol myopia," and argued alcohol intoxication
exacerbated the dynamics identified in escape theory. We suggest that
the traditional male gender role contributes its own myopia, increasing
male suicide risk. In the next section we review masculinity theory,
showing the connection between masculinity and the cognitive rigidity of
escape theory.

MASCULINITY AND SUICIDE

There is a recent tradition of literature on masculinity growing
out of men's studies that dovetails with Baumeister's theory,
underscoring men's limited range of options within the areas of
self-identity, relationships and capacity for happiness (David &
Brannon, 1976; Mahalik, 1999). Many of these theories take a
developmental perspective. Pollack (2006) formulated that boys are first
taught to hide their emotions between the ages of 3 and 5 through a
"boy code" that rewards toughness, and relies on shame to
enforce a prohibition against emotional expression or vulnerability, a
condition he called "gender straitjacketing." Across the
age-span, the straitjacket metaphor is a male-specific example of
Baumeister's theory, where cultural gender-role expectations limit
males' options when faced with stress, crisis or loss, thus
increasing their risk for self-endangering or self-harming behaviors.

The traditional male gender-role, with its values of the pursuit of
success, power, emotional control, fearlessness, and self-reliance
(Mahalik, 1999), sets the context for male gender role strain (Levant,
1996). The feelings of inadequacy generated by not meeting gender role
ideals are exacerbated by the gender role expectations themselves of
avoidance of perceived weakness, unacceptability of emotions other than
anger, and prohibitions against dependency or seeking help.

A small number of studies have investigated the influence of
masculinity on suicide risk. Hunt, Sweeting, Keoghan and Platt (2006)
found that for older participants masculinity was associated with lower
suicidal thoughts, but more traditional gender role attitudes were
associated with higher suicidal thoughts. The authors note a measurement
limitation, that their measure of masculinity tapped participants'
experience of mastery and leadership and less of the negative extremes
of the traditional male gender role such as limited emotional range and
difficulty seeking help. A recent analysis of the 1969 cohort of Swedish
military conscripts also found higher masculinity was protective against
suicide (Mansdotter, Lundin, Falkstedt, & Hemmingsson, 2009). The
measure of masculinity was a crude ranking based on occupation and
leisure interests from the original 1969 conscript assessments.

Despite the limitations of these studies, there likely is an
association of certain dimensions of masculinity and low suicide risk in
healthy and successful men. One widely used measure of gender role
orientation, the Extended Personality Attributes Questionnaire (EPAQ),
includes a masculine positive scale as well as a masculine negative
scale (Helmreich & Spence, 1981). Perhaps the positive and healthy
parts of masculinity can be reclaimed in the social reworking of gender
roles. However, it is when there is a failure to meet an expectation-
job loss, relationship break-up, perceived professional failure--that
the high masculine risk for suicide is exposed. This is consistent with
Baumeister's (1990) escape theory process which begins with a
perceived personal failure. Similarly, Mansdotter and co-authors (2009)
argued that in their study, the higher rate of suicide for the low
masculinity group could be contributed to by the "... stress of not
meeting high masculinity ideals ... " (p. 412).

A qualitative study of depressed men converges with the two
quantitative studies, and reinforces some of the central arguments of
this paper. Oliffe and colleagues (2010) interviewed 30 depressed men,
with focused attention to suicide and masculinity. They found that men
were drawn away from suicide by involvement in some masculine roles such
as positive dimensions of fathering. Other men fled into
masculine-associated pseudo-independence by pulling away from
significant others and increasing alcohol and drug use, reporting
increased suicidal thoughts. This is similar to the connection proposed
between escape suicide dynamics and traditional masculinity.

DISCUSSION

Suicide is largely a male phenomenon and has a distinct profile:
male decedents are less likely to be depressed or have received mental
health services, less likely to have made previous attempts, and more
likely to use highly lethal means. Male suicide often follows job loss,
business failure, relationship loss, or an embarrassing public
disclosure. Most of the efforts to explain male suicide focus on
individual and psychological explanations, such as unrecognized
psychopathology or a male depressive syndrome. In their emphasis on
constricted emotion, anger and impulsivity, these explanations reflect
the prevailing male gender role. It is important to recognize that a
group of male decedents who could be diagnosed with "male
depression" are men who have grown up immersed in male
socialization. As Moller (1996) stated: " ... the psychosocial
collage of suicide is comprised of structural conditions, of the
psychological state of the individual, and of the manner in which
structural or social forces converge with the personal state of the
individual and define particular life situations for individuals"
(p. 199). The understanding of male suicide has focused inordinate
attention on individual deficits, while neglecting the power of
precipitating social circumstances.

Baumeister's (1990) escape theory applies well to male
suicide. Escape theory depicts the individual struggling with some
injury to self-esteem, and shifting into a crisis mode where the
cognitive awareness of options narrows. Hufford (2001) drew the analogy
that alcohol use exacerbated this narrowing of options and cognitive
rigidity, what he termed "alcohol myopia." Higher degrees of
traditional masculinity are likely a risk factor for an "escape
suicide" much like acute alcohol use. We propose there may be a
"masculinity myopia" that increases risk of suicide. As noted
earlier, there are many cultures where we hypothesize this theory is
applicable, however this hypothesis should be explored theoretically and
empirically in a wide diversity of cultures.

In addition to a theoretical exploration, this paper is a call to
action to take on the contribution of the traditional male gender role
in suicidal behavior. The negative interpersonal and social effects of
the exaggerated social norm of masculinity found in many cultures are
clear: namely, an absence of empathy and emotions other than anger,
misogyny, homophobia, violence and an emphasis on competition and
dominance in interpersonal relationships. Part of the social influence
of feminism is freeing the experience of being a woman from constricting
social conceptions of femininity. Men have benefited from the reciprocal
influence of changing female gender roles exerting an influence on
traditional male roles, but in most of the world's societies there
has not been a strong or direct focus on male gender roles.

If men are dying of an extreme of the male gender role, the
implication is that male suicide prevention should be pursued through
tackling those dimensions of the male gender role that increase suicide
risk. At the broadest level, this suggests changing the meaning and
experience of being a man from the current norm in most societies. An
example of this broad view is found in Payne and co-authors' (2008)
proposal that reducing suicidal behaviors will require a public health
strategy that involves " ... a deconstruction of the power
structures that give rise to inequalities between men and women"
(p. 33). Of course, power structures and social roles change slowly and
haltingly, so this goal requires a long term perspective. More narrowly
and immediately, public awareness and suicide prevention efforts could
be tested that are tailored to the social dynamics of male suicide risk.

An example of a tailored public awareness campaign focused on
mental health, not just suicide, is a recent United States
Veteran's Administration campaign that centers on the phrase:
"It takes the courage and strength of a warrior to ask for
help" (www.realwarriors.net). This campaign attempts to work within
the masculine concept of the warrior, and to paradoxically use it to
increase rather than impede help-seeking behavior. We are ambivalent
about working within the stereotyped gender role, and therefore
reinforcing it, though we understand the immediacy of trying to break
down barriers to help-seeking for veterans and active duty military.

Another example is suicide gatekeeper training, the most popular
suicide prevention strategy. The most widely-used of the trainings is
"Question, Persuade, Refer" (QPR; www.qprinstitute.com). The
typical format of QPR is a two-hour didactic training, targeting
knowledge about suicide and suicide risk factors, breaking down myths
about suicide, and coaching participants to ask people at risk about
suicide and get them to professional help. QPR training involves little
or no gender specific information, and centers on identifying depression
and the link of depression and suicide, missing the male suicide pattern
we have identified in this paper. A version of QPR could be developed
that includes more information on gender differences and suicide, or
could focus on male suicide for gatekeepers working in primarily male
settings such as corrections or the military.

In many healthcare settings there is limited training in
identifying and intervening in suicide generally, let alone male
suicide. The recognition of suicidal risk among males is often limited
by healthcare services that are more adapted to treating females,
particularly in mental health and psychiatric settings (Rutz &
Rihmer, 2007).

This paper proposes a hypothesis that male suicide is in part a
function of extremes of the traditional male gender role. While we built
this argument synthesizing data from a wide range of sources, the
hypothesis should be directly tested. The few existing studies found
that positive dimensions of masculinity such as leadership and mastery
were protective against suicidal ideation and attempts. As Hunt (2006)
suggested, a study is needed that includes a measure of the extreme of
masculinity that includes constricted affect, inhibitions against
help-seeking, and acceptability of anger and violence. Further, our
theoretical perspective suggests high traditional masculinity is
particularly a risk factor for men who are thwarted in efforts to
maintain a masculine ideal by events such as job loss, illness or
disability.

In conclusion, the epidemiology of male suicide is stark: men
account for four out of five suicides in the United States, use highly
lethal means, often complete suicide in their first attempt, and do not
signal their risk to others through traditional symptoms of depression.
The unique dynamics of male suicide merit attention in research,
prevention and treatment efforts. In particular, high traditional
masculinity in men experiencing psychosocial stress in work or family
life, combined with easy access to lethal means, contributes to an
epidemic of male suicide. We look forward to the field producing
research to better understand masculinity and male suicide, developing
and testing public health and clinical interventions based on this
evolving understanding, and hopefully a changing social definition of
men and their role in society.

Kaplan, M.S., McFarland, B.H., & Huguet, N. (2009). Firearm
suicide among veterans in the general population: Findings from the
National Violent Death Reporting System. The Journal of Trauma, 67,
503-507.